Your Not Gonna Believe This!!

Nurses General Nursing

Published

I was "appointed" to do chart audits for my unit a few months ago.....no biggie. 8 chart audits a month. Well I am consistantly finding consents the MD has not signed, orders not noted, unapproved abbrev.....ect. Well my unit director came to me yesterday and said that we were "not meeting are minimium requirements.....as in too many errors" and she asked me to "correct the problems instead of marking them as incorrect" I was so taken aback.....I said "I will NOT alter/document charts on any patient, especially patients I have never cared for" I said this in a NOT-SO-NICE tone.....she just said "FINE" and walked away. I am not sure what to do about this.....any advice??

Run. Fast. Once you are away, call the state. If you want to hang in there, at the very least speak to her boss and follow the chain of command if only to protect yourself.

Ditto what everybody else has said.

The smart thing to do would be to alert the powers that be at the state now before any disciplinary action is taken against you... that way you won't just look like another disgruntled employee trying to get back at them for firing you or what not.

Jen

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ive got an idea, have her put the suggestion in writing and sign her name to it with her hospital position listed.
This is an EXCELLENT idea, I actually have memos that went between myself and a supervisor that was demanding I falsify certain documents, in the memos she signed her name, date, etc, of COURSE I made copies of these. They were presented in my hearing as evidence. This is all public record now, so I am not divulging anything can could hurt my case, at this point.
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Specializes in LTC.
Yeah. Stick to your guns on this one. It's your license and your name. As far as reporting her to her supervisor... if you do so, don't be surprised if they see nothing wrong with what she asked you to do. I've been approached many times by managers asking me to 'fix' charts. It was their routine practice for them to do so prior to a JCAHO or state inspection. I've also seen this done before magnet surveys.

I would agree to flag them as incomplete, but I absolutely refused to alter documentation. Not sure who they recruited to do that, but it did occur.

That's just freakin scary. Not that I'm surprised!

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That's just freakin scary. Not that I'm surprised!
What's scary, or rather just plain sad, is that it doesn't seem to matter anymore that our patients receive safe quality care. As long as it looks good on paper and all the i's are dotted and t's crossed.
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Specializes in med/surg, psych, public health.
This situation is a perfect example of how we are so often between a rock and a hard place. If you decide to report your mgr, be prepared to have to find another job.

^^ Amen to that.

Report her...be prepared for retaliation and document this occurence and ALL further occurences, prepare a grievance, then make a report to the HRC (human rights committee) of the state you're from as well as the EEOC!

Most states have a whistleblower act in place, I know mine does. :gtch:

Good luck and please remember...DOCUMENT, DOCUMENT, DOCUMENT!!

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Specializes in ER/ICU, CCL, EP.

1. Find a new job

2. Report it.

That totally sucks

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Specializes in A myriad of specialties.
ive got an idea, have her put the suggestion in writing and sign her name to it with her hospital position listed.

I like this idea but highly doubt that she'd do that.

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I would report it immediately. Chances are she will probably will retaliate against you either way so I would do what's right and let the powers to be know about it ASAP.

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Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

Oh I believe it, I'm so NOT surprised and will leave it at that.

I don't think reporting her to TPTB at the hospital is a good idea, she probably got the edict to do such a thing from them (they want everything to look good for JACHO you know.) She has certainly put you in a horrible position, the proverbial 'between a rock and a hard place.' Definitely don't do the falsifying she requests, no matter how hard she presses you. But you probably will need to start job-hunting very soon.

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Specializes in Nursing Professional Development.

I agree with the general themes of the other posters: do NOT falsify anything and document everything.

I would also recommend that you tread carefully and be careful not to give her any other ammunition to use against you -- and try not to stir up trouble too fast. You want to be sure you are well-prepared before things go bad. You wrote that you responded to your manager's request in a "not so nice" tone. That's just asking for trouble -- additional trouble that you don't need now. Try to maintain a pleasant demeanor to avoid having the situation suddenly blow up in your face.

My advice: Re-open the conversation with your manager and apologize for your tone. Then, as part of your reconciliation process, explain that you feel uncomfortable falsifying any records. Try to "buy yourself some time" by encourage a positive resolution. You might want to do this via a craftily worded e-mail -- one that doesn't accuse her of anything, but that says enough to be incriminating in the event that she responds back via e-mail in a way that acknowledges that she asked you to "fix" the rexords in some way. That would give you good documentation that she requested something inappropriate.

Also, locate anyone in your environment who might be able to give you some support. Ask them for advice. If no records have actually been change, it may be premature to report any "wrong-doing" to any regulatory agency.

Focus on:

1. keeping things calm to give yourself time to think things through before the situation blows up in your face

2. locating resources

3. documenting everything

4. look around at other job possibilities in case you need them in the near future

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Gazing into my crystal ball as staff RN doing audits and now manager.....

Any possibility that the manager wanted you to observe needed corrections, give to offending party for instant/immediate correction if something simple rather than just turning form in, chart having to be pulled again and info corrected at later date.

Nothing like having to audit own charts and 6 of teammates to make one more aware of dotting eyes and crossing T's AND need to apply peer pressure to repeat offenders who leave MAJOR charting errors repeatedly not addressed.

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